Validity and Reliability of the European Foot and Ankle Society (EFAS) Score in Patients With Hallux Valgus in Singapore.

The European Foot and Ankle Society score is a popular tool for monitoring treatment outcomes of foot or ankle conditions. However, few studies have assessed its psychometric properties in patients with hallux valgus. We aimed to validate the European Foot and Ankle Society score in patients with hallux valgus in Singapore. This is a cohort study of 121 patients with operatively managed hallux valgus from a tertiary referral hospital, evaluated preoperatively and at 6 months postoperatively with the primary endpoint of restoring patients to premorbid status. Internal consistency was assessed via Cronbach's alpha. Construct validity was assessed through 7 a priori hypotheses by correlating the European Foot and Ankle Society score with other patient-reported outcomes measures. Structural validity was assessed via Confirmatory Factor Analysis, whereby a good fit was indicated when Comparative Fit Index >0.95, Tucker-Lewis Index >0.95, Root Mean Square Error of Approximation <0.06, and Standardized Root Mean Residuals <0.08. Among our subjects, the European Foot and Ankle Society score demonstrated reliability, reflected by a good internal consistency (Cronbach's alpha = 0.773). Six out of the 7 a priori hypotheses were fulfilled, indicating both convergent and divergent construct validity. Structural validity was confirmed with our European Foot and Ankle Society score model which showed good fit for a 1-factor structure (Confirmatory Factor Analysis = 0.998, Tucker-Lewis Index = 0.996, Root Mean Square Error of Approximation = 0.025 [90% CI: 0-0.111], Standardized Root Mean Residuals = 0.027). In conclusion, the European Foot and Ankle Society score was validated for monitoring treatment outcomes of patients with hallux valgus in Singapore.

Motivations to exercise in young men following a residential weight loss programme conducted in National Service - a mixed methods study.

BACKGROUND: Physical activity is a critical component of lifestyle interventions to reduce body weight and maintain weight loss. The goal of this study was to examine the motivations to exercise in young men following a 5-month residential weight loss programme conducted in the Singapore military as part of National Service. METHODS: We conducted a sequential mixed methods study starting with three focus groups comprising 21 programme instructors. Fifteen former programme participants aged 20.8 years (±1.4) with an average body mass index (BMI) of 29.3 kg/m2 (±4.6) were interviewed in-depth over a total duration of 9 h. Another 487 current programme participants aged 20.8 years (±1.1), BMI 27.1 kg/m2 (±2.6), completed a survey on weight loss, physical fitness, and motivations to exercise using the Behaviours Regulating Exercise Questionnaire (BREQ-3). Qualitative data was coded thematically using the six constructs of exercise motivation described by self-determination theory: amotivation, external, introjected, identified and integrated regulation and intrinsic motivation. Quotes from interviewees were cross-tabulated according to their weight maintenance trajectories. BREQ-3 responses were analysed according to initial body mass index (BMI), percentage weight loss and fitness. RESULTS: Over the course of the residential programme interview and survey participants experienced an average weight loss of 15.6 kg (±6.5) and 13.0 kg (±5.4) respectively. Among the fifteen interviewees seven had gained no more than 34% of initial weight loss 6 months after completing the programme while another eight had gained more than 51%. We elicited three key themes from the data: (1) Barriers to exercise; (2) diminishing extrinsic motivation; and (3) unidentified exercise benefits. The integration of findings uncovered reinforcing motivational patterns in the areas of health, fitness, camaraderie and identified regulation. Narratives of self-acceptance and shift-work environments gave rise to potentially deleterious motivational patterns. Our findings suggest that successful transition from a residential programme to independent weight management requires a more deliberate pivot from predominantly extrinsic to intrinsic motivational approaches. CONCLUSION: Residential programmes such as the one investigated here, should develop a deliberate transition strategy, replace weight loss targets with physical performance goals and promote sports that are appropriate for young men affected by overweight and obesity.

Rotator Cuff Repairs With and Without Acromioplasties Yield Similar Clinical Outcomes: A Meta-analysis and Systematic Review.

PURPOSE: This meta-analysis reviews the current literature comparing the patient-reported outcome measures of patients who underwent rotator cuff repairs with and without acromioplasties. METHOD: A comprehensive literature search was performed using PubMed, EMBASE, and Scopus databases, obtaining 1,456 studies for the review. After the filtering process, 8 studies remained for our meta-analysis, of which 7 were prospective trials. From the included studies, the postoperative outcomes of 3,034 shoulders were studied. Data were analyzed using Mantel-Haenszel statistics and random-effect models where appropriate. RESULTS: Our meta-analysis revealed that there was no significant difference in American Shoulder and Elbow Surgeons scores (standardized mean difference [SMD], 0.09; 95% confidence interval [CI], -0.10 to 0.28; I2 = 9%; P = .36), University of California at Los Angeles scores (SMD, 0.17; 95% CI, -0.07 to 0.40; I2 = 0%; P = .17), and rate of further surgery (odds ratio, 0.49; 95% CI, 0.04 to 5.66; I2 = 59%; P = .57) between the acromioplasty and nonacromioplasty groups. There was a statistical difference in the Constant score (SMD, 0.25; 95% CI, 0.02 to 0.48; I2 = 0%; P = .03) of both groups. However, with the Constant score having an SMD of only 0.25, the difference in Constant score was not clinically significant. CONCLUSIONS: There were no clinically significant differences in postoperative functional scores and pain scores for patients who underwent rotator cuff repairs with and without acromioplasties. LEVEL OF EVIDENCE: Level II, meta-analysis of Level I and II studies.

Superior Postoperative Stability and Functional Outcomes With Anteromedial Versus Transtibial Technique of Single-Bundle Autologous Hamstring Anterior Cruciate Ligament Reconstruction: A Meta-analysis of Prospective Randomized Controlled Trials.

PURPOSE: The aim of this meta-analysis was to compare the postoperative stability and functional outcomes of anteromedial (AM)- and transtibial (TT)-based single-bundle hamstring anterior cruciate ligament (ACL) reconstruction techniques. METHODS: A meta-analysis comparing the outcomes of single-bundle hamstring ACL reconstruction using the AM and TT techniques was performed. Prospective randomized controlled trials identified from searches of PubMed, Cochrane, and Embase were included in this review. The outcome measures analyzed included postoperative Lachman test and pivot-shift test results, side-to-side difference, International Knee Documentation Committee (IKDC) score, Lysholm score, and Tegner activity score. RESULTS: A total of 7 randomized controlled trials (654 patients) were included in this review. The AM technique, compared with the TT technique, resulted in superior postoperative stability based on the negative Lachman test rate (risk ratio [RR], 1.12; 95% confidence interval [CI], 1.01 to 1.24; P = .03; 95% prediction interval [PI], 0.32 to 3.46), negative pivot-shift test rate (RR, 1.16; 95% CI, 1.06 to 1.28; P = .002; 95% PI, 0.40 to 2.88), and side-to-side difference (weighted mean difference [WMD], -0.32 mm; 95% CI, -0.48 to -0.16; P < .0001; 95% PI, -0.55 to -0.09). Likewise, the AM technique contributed to superior postoperative functional outcomes based on the proportion of IKDC grade A findings (RR, 1.16; 95% CI, 1.02 to 1.32; P = .03; 95% PI, 0.40 to 2.83) and the Lysholm score (WMD, 0.82; 95% CI, 0.23 to 1.41; P = .007; 95% PI, -0.22 to 1.86). However, the AM and TT techniques had comparable subjective IKDC scores (WMD, 0.98; 95% CI, -0.91 to 2.88; P = .31; 95% PI, -3.18 to 5.14) and Tegner activity scores (WMD, 0.32; 95% CI, -0.23 to 0.86; P = .25; 95% PI, -3.84 to 4.48). CONCLUSIONS: The AM method of single-bundle hamstring ACL reconstruction results in superior postoperative stability and functional outcomes compared with the TT method. LEVEL OF EVIDENCE: Level I, systematic review of Level I studies.

Clinical Outcomes of Open Versus Arthroscopic Broström Procedure for Lateral Ankle Instability: A Meta-analysis.

Arthroscopic repair of the anterior talofibular ligament is becoming increasingly popular as a surgical option for lateral ankle instability. However, studies directly comparing outcomes of open and arthroscopic anterior talofibular ligament repair continue to present conflicting conclusions. This review aims to compare the clinical outcomes of arthroscopic and open Broström procedure. A systematic literature review was performed using MEDLINE, Cochrane Library, and EMBASE from January 2010 to March 2020 to identify all clinical studies (level of evidence I-III) comparing outcomes of arthroscopic versus open Broström procedure for chronic lateral ankle instability. Six studies were included in this review. The arthroscopic technique, compared to the open technique, resulted in higher American Orthopaedic Foot and Ankle Society scores (weighted mean difference [WMD] = 1.20, 95% confidence interval [CI]: 0.05-2.34, p= .04), higher Karlsson scores (WMD = 1.86, 95% CI: 0.46-3.25, p= .009) and lower Visual Analog Scale pain scores (WMD = -0.31, 95% CI: -0.51 to -0.10, p= .003). There were no differences between the groups in terms of postoperative anterior drawer test (WMD = -0.10, 95% CI: -0.60 to 0.39, p= .68), talar tilt (WMD = 0.31, 95% CI: -0.10 to 0.72, p= .14) or overall complication rates (odds ratio [OR] = 0.78, 95% CI: 0.37-1.64, p= .51). The odds of wound-related complications in arthroscopic Broström procedures was significantly lower than that of open Broström procedures (OR = 0.25, 95% CI: 0.07-0.95, p= .04). Current evidence shows that arthroscopic repairs offer comparable clinical outcomes with a lower wound complication rate, compared to traditional open repairs.

Risk factors of lateral epicondylitis: A meta-analysis.

INTRODUCTION: Lateral Epicondylitis is commonly associated with numerous anatomical and mechanical risk factors. Thus far, there have been no reviews synthesising the risk factors of lateral epicondylitis. We hence aimed to perform a meta-analysis of factors associated with lateral epicondylitis. METHODOLOGY: We searched MEDLINE, Scopus and Web of Science for 1032 articles. Eventually, based on our exclusion criteria, we had 33 articles remaining for our systematic review. 15 of these articles were used for our meta-analysis. Data was analysed using Mantel-Haenszel statistics and random effect models where appropriate. RESULTS: Females had a 1.29 times higher odds of sustaining lateral epicondylitis (OR Males: Females = 0.77, 95% CI = 0.67-0.89, Z = 3.52, I2 = 33%, p < 0.001). The odds of an individual with a current or past tobacco smoking history sustaining lateral epicondylitis was 1.49 times that of an individual with no tobacco smoking history (95% CI = 1.18-1.87, Z = 3.40, I2 = 0%, p < 0.001). There was no statistical difference in sustaining lateral epicondylitis when comparing individuals with a current tobacco smoking history to individuals with a past or no tobacco smoking history (OR = 1.18, 95% CI = 0.91-1.51, Z = 1.26, I2 = 0%, p = 0.21). Neither was there a statistical difference in sustaining lateral epicondylitis when comparing individuals with a BM ≥ 25 to those with a BMI<25 (OR = 1.12, 95% CI = 0.69-1.83, Z = 0.46, I2 = 62%, p = 0.65). CONCLUSION: Female gender and a positive and past smoking history were associated with lateral epicondylitis. Further studies should focus on identifying other associations with lateral epicondylitis and the pathophysiological explanation of such associations.

Use of single-question screening for erectile dysfunction: a study of at-risk Asian men in primary health care.

This study assesses the validity of a single-question screener for erectile dysfunction (ED) in men at risk in comparison to a standard validated tool - the five-item version of the International Index of Erectile Function (IIEF-5). A total of 174 men with at least one risk factor for ED were studied, with 58.0% and 10.9% of the study respondents meeting the criteria for their erectile impairment by IIEF-5 and single-question screener respectively. Our results suggest that in spite of high feasibility, a simplified, single-question screener has low sensitivity in capturing ED prevalence, even in an at-risk population, within the Asian context.

Validity and Reliability of the American Orthopaedic Foot and Ankle Society Score for the English-Literate Singapore Population With Hallux Valgus.

BACKGROUND: This study aimed to evaluate the reliability and validity of the American Orthopaedic Foot and Ankle Society Metatarsophalangeal-Interphalangeal (AOFAS MTP-IP) score in patients with hallux valgus in Singapore. METHOD: A total of 121 English-literate patients with hallux valgus identified between October 2017 and May 2020 were analyzed. Reliability was assessed via Cronbach α. Construct validity was evaluated through 20 a priori hypotheses by correlating the AOFAS MTP-IP score for hallux and lesser toes with other patient-reported outcome measures (PROMs). Standardized response means (SRMs) were calculated to evaluate responsiveness at 6 months postoperative. Structural validity was evaluated via confirmatory factor analysis (CFA) whereby a good fit was indicated when comparative fit index (CFI) is >0.95, Tucker-Lewis index (TLI) is >0.95 and standardized root mean residual (SRMR) is <0.08. RESULTS: The AOFAS MTP-IP score demonstrated reliability with a Cronbach α of 0.837. Convergent construct validity was confirmed when all a priori hypotheses were fulfilled. Structural validity was established with our AOFAS MTP-IP score model that displayed good fit for a 1-factor structure (CFI = 0.988, TLI = 0.960, SRMR = 0.034). Responsiveness of the AOFAS MTP-IP score for hallux was demonstrated by an SRM score of 1.28. CONCLUSION: The AOFAS MTP-IP score displayed adequate reliability and validity among English-literate patients in Singapore with an operatively managed hallux valgus. LEVEL OF EVIDENCE: Level III: Retrospective cohort study.

Financial burden and financial aid for medical students in Singapore: a national survey across all three medical schools.

INTRODUCTION: Singapore has had three medical schools since 2013. We undertook a cross-sectional quantitative national survey to determine the financial impact of medical education on medical students in Singapore. METHODS: All 1,829 medical students in Singapore were invited to participate in this study. Information on demographics, financial aid utilisation and outside work was collected and analysed. RESULTS: 1,241 (67.9%) of 1,829 students participated in the survey. While the overall proportion of students from households with monthly incomes < SGD 3,000 was only 21.2% compared to the national figure of 31.4%, 85.4% of medical students expected to graduate with debts > SGD 75,000. There were significant differences in per capita incomes among the schools, with 54.5%, 23.3% and 7.8% of Duke-NUS Medical School (Duke-NUS), NUS Yong Loo Lin School of Medicine (NUS Medicine) and Lee Kong Chian School of Medicine (LKCMedicine) students, respectively, reporting a per capita income of < SGD 1,000 (p < 0.001). There were significant differences in financial support: 75.0%, 34.1% and 38.8% of Duke-NUS, NUS Medicine and LKCMedicine students, respectively, received financial aid (p < 0.001). The top reasons for not applying for aid included a troublesome application process (21.4%) and the perception that it would be too difficult to obtain (21.0%). CONCLUSION: Students in the three medical schools in Singapore differ in their financial needs and levels of financial support received. A national approach to funding medical education may be needed to ensure that financial burdens do not hamper the optimal training of doctors for Singapore's future.

Comparison of clinical outcomes between knotted and knotless double-row arthroscopic rotator cuff repairs: a meta-analysis.

BACKGROUND: The ideal rotator cuff repair technique should allow for a quick and simple arthroscopic application which provides both adequate biomechanical stability and an appropriate biological state with the intention of promoting eventual healing of tendon to bone. While the biomechanical superiority of double-row repairs including higher repair strength, reduced gap formation, and wider footprint restoration have been proven, controversy remains regarding the clinical benefits of knotless compared with knot tying techniques. Our study aims to review the available evidence in the literature comparing the clinical outcomes between knotted and knotless transosseous double-row rotator cuff repair techniques. METHODS: A systematic literature search via PubMed, Embase, and Scopus was conducted by 2 independent reviewers. Studies reporting clinical outcomes of arthroscopic rotator cuff repair using the double-row knotted and knotless surgical techniques were identified. Data were analyzed with Review Manager 5.3, using Mantel-Haenszel statistics with both fixed and random effect models. RESULTS: A total of 1144 studies were identified from our initial search. Based on our inclusion and exclusion criteria, 8 studies were eventually selected for our review. The selected studies were published between 2012 and 2018. Of the 8 studies, 3 reported level 2 evidence and 5 reported level 3 evidence. There were a total of 589 subjects. Our meta-analysis revealed that there were no significant differences in functional outcomes postoperatively when comparing Constant score (mean difference = -1.85, 95% confidence interval: -4.42 to 0.73), University of California at Los Angeles score (mean differences = -0.14, 95% confidence interval: -0.90 to 0.62), and American Shoulder and Elbow Surgeons score (mean differences = -2.19, 95% confidence interval: -5.55 to 1.17) between patients who underwent knotted and knotless rotator cuff repairs. DISCUSSIONS AND CONCLUSION: Our review revealed no statistically significant difference in functional outcomes between knotted and knotless transosseous double-row techniques for arthroscopic rotator cuff repairs. To our knowledge, this is the first meta-analysis related to this topic. However, no level 1 studies were available for this review. Further studies related to this topic should focus on reporting level 1 evidence comparing the clinical outcomes of knotless and knotted techniques for double-row repairs.

Impact of financial background and student debt on postgraduate residency choices of medical students in Singapore.

INTRODUCTION: Medical school fees are rising globally. Student debt and financial background may affect residency choices, but few studies have been conducted in Asia. This study aimed to explore the relationship between financial background, student debt and postgraduate residency choices among medical students in Singapore. METHODS: An anonymised survey of all medical students in Singapore was conducted and had a response rate of 67.9%. RESULTS: 40.5% of our study population would graduate with debt. Medical students with monthly per capita household income < SGD 1,000 were more likely to graduate with debt (unadjusted odds ratio [OR] 2.0, 95% confidence interval [CI] 1.6-2.7; p < 0.001) and feel burdened by the cost of medical education (unadjusted OR 2.8, 95% CI 2.0-3.9; p < 0.001). Students with monthly per capita household income < SGD 1,000 (unadjusted OR 1.818, 95% CI 1.338-2.470, p < 0.001; adjusted OR 1.692, 95% CI 1.202-2.381, p = 0.003) and those with debt (unadjusted OR 1.623, 95% CI 1.261-2.090, p < 0.001; adjusted OR 1.393, 95% CI 1.048-1.851, p = 0.022) were more likely to rank at least one economic factor as 'very significant' in influencing their postgraduate training choices. CONCLUSION: It is concerning that despite financial aid schemes, the cost of medical education remains a burden to students from lower-income households in Singapore. Student debt and financial background may distort postgraduate career choices, creating an undue push towards high-paying specialties.

Systematic review on risk factors of rotator cuff tears.

PURPOSE: Rotator cuff tears (RCTs) occur commonly, especially among certain groups of individuals. In this meta-analysis, we aim to identify risk factors for RCTs. METHODS: We searched MEDLINE for 210 articles. Seventeen articles were selected for systematic review, of which 10 were eligible for meta-analysis. Data was analysed with Review Manager 5.3, using Mantel-Haenszel statistics and random effect models. RESULTS: A total of 6653 individuals were analysed. The odds of sustaining a RCT on the dominant hand was 2.30 times more than the non-dominant hand (95% confidence interval (CI): 1.01-5.25, Z = 1.99, p = 0.05; Heterogenity: τ2 = 0.38, χ2 = 8.84, df = 2 ( p = 0.01), I2 = 77%). The odds of an individual aged 60 years and above sustaining a RCT was 5.07 times higher than an individual less than 60 years old (95% CI: 2.45-10.51, Z = 4.37, p < 0.001; Heterogenity: τ2 = 0.47, χ2 = 25.24, df = 3 ( p < 0.001), I2 = 88%). Female gender was not a significant association, with an odds ratio of 0.98 when compared to the male gender (95% CI: 0.66-1.45, Z = 0.09, p = 0.93; Heterogenity: τ2 = 0.20, χ2 = 44.24, df = 5 ( p < 0.001), I2 = 89%). CONCLUSIONS: Hand dominance and older age are associated with RCTs. More studies are required for further assessment of associations and risk factors of RCTs.

Barriers and enablers to proper diabetic foot care amongst community dwellers in an Asian population: a qualitative study.

BACKGROUND: Diabetic foot complications are common within Asian populations. They arise due to poor diabetic control and foot care. In this study, we aimed to identify the causes for proper and improper diabetic foot care. METHODS: A qualitative study consisting of key informant interviews with 17 healthcare professionals, including doctors and various allied health workers, was conducted. Participants included had at least five years of caring for diabetic foot patients either in public institutions or private clinics. Data collected was analyzed via thematic analysis. RESULTS: Diabetic patients were generally observed to have a mixture of proper and improper information and beliefs which eventually resulted in the extent of proper foot care. Factors which influenced the extent of proper and improper state of information and beliefs were classified into predisposing and precipitating factors. Predisposing factors were further categorised into modifiable factors (e.g., education level, socioeconomic status, social support) and non-modifiable factors (e.g., age, presence and severity of co-morbidities restricting ability to selfcare, past experiences). Precipitating factors were categorized into patient factors (e.g., degree of reception of information, presence of psychological barriers), provider factors (presence and degree of multi-disciplinary approach to care, presence of administrative inconveniences) and disease factors (presence of diabetic sensory neuropathy, complexity of disease process). CONCLUSIONS: The extent of proper foot care amongst diabetic patients is influenced by numerous predisposing and precipitating factors. Further studies can look at further development of the described structure as well as quantitatively defining the various components and factors which make up the described system.

Arthroscopic management of posterior instability of the shoulder: A systematic review of predictive factors associated with poorer surgical outcomes.

INTRODUCTION: We aimed to perform a systematic review to identify factors that may lead to poorer outcomes in arthroscopic surgery for posterior shoulder instability. METHODS: We searched MEDLINE, Embase and the Cochrane Database of Systematic Reviews for 757 unique articles. We eventually included 22 articles. Data were analysed using Review Manager 5.3. RESULTS: The presence of chondral damage was associated with poorer outcomes as reflected in a higher post-operative Quick Disabilities of theArm, Shoulder and Hand score (mean difference (MD) = 17.1; 95% confidence interval (CI) = 2.82-31.4; p = 0.02), higher WesternOntario Shoulder Instability (WOSI) index (MD = 468.0; 95% CI = 136.5-799.5; p = 0.006), lower Simple Shoulder Test score (MD = -2.40; 95% CI = -4.34 to -0.46; p = 0.02) and a lower Single Assessment Numeric Evaluation score (MD = -15.4; 95% CI = -30.6 to -0.23; p = 0.05). The presence of previous shoulder surgery was associated with poorer outcomes as depicted by a lower American Shoulder and Elbow Society (ASES) score (MD = -93.1; 95% CI = -96.9 to -89.3; p < 0.0001). The availability of workers' compensation was associated with poorer outcomes as revealed by a lower rate of return to work (odds ratio (OR) = 0.02; 95% CI = 0.00-0.20; p = 0.0008). The presence of additional procedures while performing surgery for posterior shoulder instability was associated with poorer outcomes as reflected by lower ASES scores (MD = -6.70; 95% CI = -8.64 to -4.76; p < 0.0001), higher WOSI index (MD = 63.4; 95% CI = 33.0-93.8; p < 0.0001), lower University of California at Los Angeles (UCLA) scores (MD = -2.30; 95% CI = -2.81 to -1.79; p < 0.0001), higher pain scores (MD = 0.72; 95% CI = 0.39-1.05; p < 0.0001) and higher post-operative instability (MD = 0.80; 95% CI = 0.57-1.03; p < 0.0001). CONCLUSION: The presence of chondral damage, previous shoulder surgery, concomitant surgery and workman's compensation was associated with poorer outcomes for arthroscopic repair of posterior shoulder instability. Further studies should be done to further validate these factors.

Epidemiology of surgically managed anterior cruciate ligament ruptures in a sports surgery practice.

INTRODUCTION: Anterior cruciate ligament (ACL) tears are common knee injuries, especially among sportsmen and sportswomen. The aim of this study is to better understand the epidemiology of surgically managed ACL tears sustained in our institution. METHODS: All patients who underwent arthroscopic ACL reconstruction by the senior author of this article in Singapore from 2008 to 2013 were studied. Patients who were diagnosed clinically and/or radiologically to have a complete tear of the ACL and subsequently underwent arthroscopic ACL reconstruction were included. Patients who suffered from traumatic knee dislocation were excluded. Two hundred and ninety-two patients were available for analysis. All patients were operated on by the senior author. RESULTS: 83.9% of patients were male. 60.5, 23.0, 8.46, and 8.11% were of Chinese, Malay, Indian and other origins, respectively. 69.6 and 28.7% were in white-collared and blue-collared jobs, respectively, while 1.69% were unemployed. Mean age at operation was 29.4 years. Mean body mass index was 25.3 kg/m2. 82.4 and 17.6% of ACL tears were sports (contact-27.5%; non-contact-72.5%) and non-sports injuries (activities of daily living-94.2%, road traffic accidents-5.77%), respectively. The top four sporting activities causing ACL tears were soccer, basketball, racquet games and volleyball. 56.2% of ACL tears presented with concomitant knee injuries (medial meniscus-63.4%; lateral meniscus-31.1%; posterior cruciate ligament-5.49%). 84.5% were primary tears. CONCLUSIONS: In this epidemiological review of ACL injuries, we found that ACL injuries tend to cluster within certain population subgroups. Patterns of mechanisms of injuries have been observed. These findings may lead to better preventive and treatment strategies in the management of ACL tears.

An update on finances and financial support for medical students in Yong Loo Lin School of Medicine.

INTRODUCTION: Increasing financial challenges have resulted in great debt among medical graduates worldwide. In Singapore, more scholarships and bursaries have been disbursed in recent years to support students who are financially challenged. We aimed to study the financial status of medical students in National University of Singapore (NUS) Yong Loo Lin School of Medicine (i.e. NUS Medicine), Singapore, and the financial support available to them. METHODS: A cross-sectional quantitative study was performed. Surveys were distributed and completed by medical students of NUS Medicine. Information regarding household income, financial assistance, monthly allowance and expense, and concurrent occupations was collected. We compared our findings with the results of a similar study performed in 2007 and national income data. RESULTS: A total of 956 (66.2%) out of 1,445 medical students completed the survey. 19.5% and 58.5% of respondents came from households with monthly incomes < SGD 3,000 and > SGD 7,000, respectively. 20.6% of students had loans, 18.9% had scholarships and bursaries, and 14.4% worked to support themselves. CONCLUSION: Medical school fees have risen by more than 50% over the past ten years. Our study found that there were increases in the proportion of students from both the lower- and higher-income segments, with proportionally fewer students from the middle-income segment. A large number of students were working and/or had some form of financial support. More should be done to meet the needs of financially challenged medical students to ensure equal access to quality medical education.

Anterior cruciate ligament ganglion causing flexion restriction: a case report and review of literature.

Ganglion cysts originating from the anterior cruciate ligament (ACL) are uncommon. Often asymptomatic, they infrequently present with non-specific symptoms such as knee pain, stiffness, clicks, locking or restriction of knee extension. However, the patient we report presented with knee flexion restriction. A 37-year-old Chinese gentleman, with no history of knee trauma, presented with left knee pain. Left knee range of motion (ROM) was from 0 to 110 degrees. Magnetic resonance imaging (MRI) scan revealed a 1.5 cm × 3.3 cm × 1.7 cm cyst located in the intercondylar region arising from the ACL and extending predominantly posteriorly. Arthroscopy confirmed an intrasubstance ACL ganglion cyst, which was extending posteriorly. Complete excision of the cyst was performed. At 1-year follow-up, the patient regained knee flexion of 130 degrees. We describe one of the largest ACL ganglion cysts. Such cysts often extend anteriorly and impinge onto the roof of the intercondylar notch during knee extension, thus restricting extension. The restriction in knee motion in our patient was in flexion instead; this was because the cyst took an unusual course of extension predominantly in the posterior direction. Although rare, it must be included as a possible differential diagnosis when patients present with such knee symptoms.

Mental health issues amongst medical students in Asia: a systematic review [2000-2015].

BACKGROUND: Studies have shown that the stress experienced by medical students is far greater than that experienced by other university students. In this study, we aim to understand the consequent mental health issues that are experienced by medical students, particularly in Asia, via a systematic review of the current literature. METHODS: Initial searches on MEDLINE, Embase and SpringerLink came up with a total of 1,033 unique articles. Studies not focusing on medical students alone, not mentioning mental health issues or not containing prevalence values were excluded. RESULTS: We included 14 articles in our analysis. ADs had a prevalence of 7.04% (100/1,420). Depression was prevalent in 11.0% (1,115/10,147) of students. A total of 12.9% (54/420) and 12.9% (41/319) of male and female medical students respectively were screened for depression. Preclinical students were also 1.63 times more likely to be depressed compared to clinical students, with 98.0% (48/49) pre-clinical students having screened for depression, compared to 60% (27/45) clinical students. Home staying medical students are 1.33 times more likely to be depressed compared to hostel-stayers, with 12.1% (29/239) of home stayers being depressed compared to 9.2% (37/402) of hostel stayers. CONCLUSIONS: We found that mental health issues affect a significant proportion of medical students and they are more prevalent in certain subpopulations of medical students. Our data revealed that preclinical and home staying students can be more susceptible to depression. More research should be done regarding this issue. With such information, it is hoped that appropriate interventions can be designed to improve the mental health of medical students.